Facing Our Doubts

In the past few months, a new note of pessimism -- some call it a reality check -- has crept into the headlines, suggesting that the honeymoon period of HIV drugs is over. "Welcome to the real world," reply people with HIV and their care providers as they outline the formidable obstacles that continue to limit access to quality care and quality of life for so many.

The issues are numerous and serious. While the advent of protease inhibitors has dramatically decreased HIV death rates and given many people a new lease on life, others are being left out, especially those who are often the most vulnerable and have the fewest resources when it comes to health care: Women, youth, African-Americans, and Latinos. A recent study by Emory University researchers confirms a disturbing trend: Despite the availability of new drugs, the rates of HIV illnesses and hospitalizations haven't dropped among people attending inner-city hospitals. Instead, the poor and homeless remain shut out of even basic care, and other surveys break the access issue down along clear dividing lines of race and lack of insurance. At San Francisco General Hospital, a new study shows that expense is the main reason people aren't getting the latest drugs, and that whites are more likely to get the drugs than African-Americans.

In this issue, we've spotlighted these real-world issues by looking at what's happening to those on the street who are at high risk for HIV or living with the virus. For this large but overlooked population, getting access to HIV care means first dealing with food, shelter, and basic needs. Within this group, prostitutes require special outreach. Fortunately, help is available from those who have survived the streets themselves and are using their experiences to educate others. So listen up.

In terms of the virus itself, there's been a new concern about problems associated with long-term therapy. In this issue, senior writer Emily Bass looks at what we have learned about drug-related side effects and how to manage them. She also explores a phenomenon that offers hope to those who are experiencing drug failure, or "viral rebound," after months of successful drug therapy. Though potent therapies may not completely knock out the virus, they might deal enough of a blow to make the infection less dangerous, allowing people to stay healthy longer.

How long this will last is a difficult question no one can answer, but again, it's important to have an informed perspective. Just a few short years ago millions of people were dying of AIDS without any real hope that drugs could help. Now we've got imperfect tools, but we're constantly improving them, and for those who benefit, they represent a real weapon. That leaves the significant barrier of latent infection, the new frontier of HIV research. Here, the big picture is very sobering, showing that a tiny amount of virus gets into our bodies early and lies undetected in tissue reservoirs, serving as a source for potential reinfection. We've also found that some people who were thought to be HIV-negative carry latent infection, as do some long-term survivors who remain healthy. These discoveries raise serious public health questions: How many other people harbor dormant HIV? What is the risk in terms of transmission? Do we need to revise current testing methods to track this silent spread? And finally, what does it mean for people now on therapy-or those who aren't?

In this issue, I've taken a comprehensive look at where and how HIV hides and may silently spread. What's emerging is a new view of the battle: Instead of a single, ongoing war pitting the immune system against HIV, the fight erupts and simmers on many smaller, local fronts. There's also new evidence that latent infection may last a person's lifetime, unless new drugs are developed that can reach these protected reservoirs. But as you'll see, there's debate over nearly every aspect of HIV latency. For now, the news has caused us to reshift our treatment goals away from eradication and onto remission, using current drugs to keep the virus in check.

As we move forward then, it helps to view our progess against the virus as dynamic. For every step forward, we should anticipate setbacks. We've made enormous strides in the past decade, which should provide us with a perspective for dealing with the new fears and obstacles we face. It may sound clich&3tilde;d to some, but hope and faith are a powerful antidote to doubt and fear during difficult times. Getting real about HIV means being realistic about where we stand now and where we hope to stand tomorrow. It also means having courage to believe in the future.

ANNE-CHRISTINE D'ADESKY
EDITOR IN CHIEF